The document summarizes a nursing assessment, plan, interventions, and evaluation for a patient. It includes the patient's subjective complaints, objective findings, nursing diagnoses, goals of care, independent and implemented interventions with rationales, and evaluation of goals. The nursing interventions focused on increasing activity tolerance, maintaining fluid balance, and managing acute pain. After various nursing interventions over 1-2 weeks, the patient was able to maintain activity levels but not fully eliminate weakness, goals for fluid management were met, and pain was able to be verbalized and addressed.
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ASSESSMENT SUBJECTIVE: “parang Hinang Hina Siya” as Verbalized by The
The document summarizes a nursing assessment, plan, interventions, and evaluation for a patient. It includes the patient's subjective complaints, objective findings, nursing diagnoses, goals of care, independent and implemented interventions with rationales, and evaluation of goals. The nursing interventions focused on increasing activity tolerance, maintaining fluid balance, and managing acute pain. After various nursing interventions over 1-2 weeks, the patient was able to maintain activity levels but not fully eliminate weakness, goals for fluid management were met, and pain was able to be verbalized and addressed.
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The document summarizes a nursing assessment, plan, interventions, and evaluation for a patient. It includes the patient's subjective complaints, objective findings, nursing diagnoses, goals of care, independent and implemented interventions with rationales, and evaluation of goals. The nursing interventions focused on increasing activity tolerance, maintaining fluid balance, and managing acute pain. After various nursing interventions over 1-2 weeks, the patient was able to maintain activity levels but not fully eliminate weakness, goals for fluid management were met, and pain was able to be verbalized and addressed.
Direitos autorais:
Attribution Non-Commercial (BY-NC)
Formatos disponíveis
Baixe no formato DOC, PDF, TXT ou leia online no Scribd
SUBJECTIVE: Activity in After one INDEPENDENT: INDEPENDENT: GOAL
tolerance week of PARTIALLY “parang hinang related to nursing Encouraged Encouraged To reduce MET. hina siya” as generalized interventions, adequate rest adequate rest cardiac verbalized by the periods periods workload Patient was able body the patient patients mother. To reduce to maintain weakness will maintains energy secondary to activity level activity within OBJECTIVE: Assist patient with Assisted patient expenditure present within ADL with ADL capabilities but but avoid illness. capabilities doing for was not able to and absence patient what he eliminate body of weakness can do; to weakness increase self esteem Planned activities Planned Encourage for the patient activities for the physical patient activity consistent with Progress activity patients energy gradually Progressed resources activity gradually To prevent over exerting Encourage ROM the heart and exercises Encouraged ROM promote short exercises range goals To maintain muscle strength and joint range of motion ASSESSMENT NURSING PLANNING SELECTIVE IMPLEMENTED RATIONALE EVALUATION DIAGNOSIS INTERVENTIONS INTERVENTIONS
SUBJECTIVE: Fluid Within 2 days GOAL MET
volume of providing “parang dehydrated deficit r/t nursing care, Maintain accurate Maintained patient may reduce AS na sya” as severe will maintain fluid intake during EVIDENCED Intake and Output accurate Intake periods of crisis verbalised by the dehydration fluid and BY and Output because of malaise, patients mother to consider electrolytes anorexia,and so on electrolyte volume at a ABSENCE OF imbalance functional SIGNS OF OBJECTIVE: .reduction of 2˚ Acute level as circulating blood SEVERE Monitor Monitored Gastroenteriti evidenced by: volume can occur DEHYDRAT- Watery,loose v/s,comparing v/s,comparing from ↑fluid loss stool(6x/day) s - will defecate ION with patient’s with patient’s resulting in in mod. amt semi-formed hypotension and stool at lest 2 normal/ previous normal/ Vomited tachycardia 5x/shift with times a day readings previous sticky - will readings symptoms reflective of vomitus in DHN/ manifest hemoconcentration scanty amount moist lips and Observe for Observed for with consequent Sunken mucous fever, changes in fever, changes vasoocclusive state. eyeballs noted membranes LOC,skin turgor, in LOC,skin Dry lips & and capillary dryness of skin mucus turgor, refill in 2-3 and mucous dryness of membrane seconds noted. membranes, pain. skin and mucous membranes, replaces pain. losses/deficits. Fluids Administer fluids must be given as indicated Administered immediately to fluids as decrease hemoconcentration a indicated prevent further interaction ASSESSMENT NURSING PLANNIN SELECTIVE IMPLEMENTED RATIONALE EVALUATION DIAGNOS G INTERVENTIONS INTERVENTIONS IS
SUBJECTIVE: Acute pain After Encourage Encouraged GOAL MET
“masakit po yung related to 2hours of patient to patient to To determine tiyan ko” as present nursing verbalize verbalize the extent of PATIENT illness feeling of pain the WAS ABLE verbalized by the interventio feeling of pain patient is TO client n the pain feeling and VERBALIZE patient will how the Pain described by RELIEF OF verbalize patient copes the client as up with it PAIN relief of pinching like pain pain Instruct in use Instructed in (pain scale not Relaxation applicable) of relaxation use of helps to techniques relaxation decrease the OBJECTIVE: such as techniques patients focused such as perception of (+) facial breathing or focused pain grimace listening to a breathing or (+) guarding story etc. listening to a behaviour at Place patient story etc. the abdomen in semi Placed To minimize fowlers patient in pressure on position semi fowlers the abdomen Encourage position To divert diversional Encouraged attention of activities diversional the patient such as activities from pain watching tv such as etc. watching tv To promote rest Maintaine etc. will help reduce bed rest Maintained pressure on bed rest abdomen.